Sunday, July 11, 2004

We Care: Timothy Noah wonders why Cheney's doctor's addiction is such a big deal, and figures it must be getting such prominent treatment because it casts a bad light - no matter how indirectly - on Cheney and his health. But news about drug addiction in prominent doctors always gets big play. Especially when those doctors have been in the media spotlight, as the Vice-President's doctor has been. When the drug problems of a prominent plastic surgeon in our town became front page news a couple of years ago, the newspaper's ombudsman defended the story's prominence by citing the number of times the paper had quoted him as an authority on various plastic surgery techniques. They felt they had a duty to make the public aware of his drawbacks having given him so much free publicity (which undoubtedly helped his practice.) Surely, there a lot of people in D.C. who chose George Washington Medical Center, and specifically Dr. Malakoff or one of his partners because the Vice-President is a patient. The publicity in this case, seems justified.

The psychiatrist and neurologist overseeing care for Malakoff -- then the director of the medical center's internal medicine division -- repeatedly prescribed the drugs the internist was known to have been abusing, medical charts show.

And when the neurologist, Perry Richardson, needed to document Malakoff's progress to the local medical society, he let Malakoff craft the letter, Richardson acknowledged in a deposition.

'I have no concerns about his thought processes or judgment,' Malakoff wrote about himself for Richardson's signature. 'I truly believe that he is stable enough to see and take care of patients as well as teach our medical students and residents.'

....What is known is that in the course of Malakoff's treatment, Richardson, the neurologist, prescribed fiorinal and codeine, two drugs that Malakoff had been abusing, with the stated aim of helping Malakoff deal with headaches and sinus pain. Malakoff's psychiatrist, Perman, added Xanax and Ambien to the mix -- two drugs Malakoff had used heavily during his times of drug dependence.

Perman said yesterday that prescribing drugs that the patient has had trouble kicking can help a physician develop a "relationship" with the patient before gradually discontinuing the drug. But he conceded that others would strongly disagree.

Those prescriptions gave Malakoff plausible deniability for his occasional positive drug tests. The real question, several doctors said, is how Malakoff managed to pass virtually all of those tests -- more than 150 of them in one stretch, according to one doctor who was monitoring his progress.

It goes without saying that an impaired doctor should at the very least find a doctor outside his own institution or practice to take care of his rehab. Throughout the process, if his driving record is any indication (which it usually is), he remained impaired:

In the early years of his treatment -- the only period for which records were obtained -- Malakoff had multiple automobile accidents. Repair shop records, citations and other documents indicate he had at least 20 crashes between April 1998 and October 2001. Many of them were on the George Washington Parkway, which he would drive daily from his home in Great Falls, and several involved rental cars he had while his car was in for repairs.

Now that's a problem.

The Broader Lesson: Sad to say, this permissive approach to the drug-impaired patient isn't limited to patients who happen to be doctors or influential members of society. I've witnessed more examples than I care to tell you of doctors who continue to prescribe addictive meds to patients with known drug problems. When confronted, they always defend themselves with "But he has real pain that needs to be treated," or "He has an anxiety disorder. We can't let him suffer." The explanation is usually accompanied by a baleful stare that implies the questioner (yes, that would be me) is some sort of hard-hearted Torquemada who enjoys the suffering of others.

The bottom line is that some people are more gullible than others. And the dedicated drug addict is particularly adept at finding them and using them, be he a doctor or an assembly line worker. It's our duty as medical professionals to remain forever vigilant.